Basic Information
| Provider Information | |||||||||
| NPI: | 1356675813 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VON BRIESEN | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VON BRIESEN | ||||||||
| OtherFirstName: | PEGGY | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH, D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 320 E JUNEAU ST | ||||||||
| Address2: | |||||||||
| City: | TOMAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546602626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085670301 | ||||||||
| FaxNumber: | 6083721224 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 E VETERANS ST | ||||||||
| Address2: | 116 B | ||||||||
| City: | TOMAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546603105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083723971 | ||||||||
| FaxNumber: | 6083721224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2009 | ||||||||
| LastUpdateDate: | 03/16/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2852-057 | WI | Y | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 071007861 | IL | N | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.